Michigan monkeypox outbreak: Testing, treatment limited
More than 1,800 Americans have been diagnosed with monkeypox amid an unprecedented global outbreak of a virus that doesn’t ordinarily spread far outside its endemic areas in central and western Africa.
Sixteen people from Michigan — six from Oakland County, four from the city of Detroit, three from Macomb County, two from Kent County and one from Wayne County — were included among those with confirmed infections in the U.S. as of Monday, state health officials told the Free Press.
The Michigan Department of Health and Human Services would not disclose whether any of the Michigan cases are connected, whether any of the people with monkeypox are hospitalized or fall into the high-risk category of men who have sex with men.
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While Michigan’s caseload is small compared with places like New York City, which has the biggest monkeypox outbreak in the U.S. with 618 cases as of July 18, it’s a number that’s likely to rise in the days and weeks ahead.
“We certainly believe there are a lot of cases that are not being diagnosed,” said Dr. Mary Foote, medical director of the office of emergency preparedness and response for the New York City Department of Health and Mental Hygiene.
Part of the reason is not enough doctors are educated about the signs and symptoms of monkeypox and recognize when a person should be tested, said Dr. Lilian Abbo, a professor of clinical infectious diseases at the University of Miami Miller School of Medicine and a member of the board of directors for the Infectious Disease Society of America.
The rash can be confused with sexually transmitted diseases in some patients. Others may have both monkeypox and an STD at the same time.
“We have seen patients that have been going up to seven centers — three different urgent cares, dermatologists and ERs — to try to figure out what’s going on,” Abbo said. “By the time they arrive, some of them may have been healed or some of them may have progression of disease.”
Getting approval from public health labs to test patients isn’t always simple, either, Abbo said.
“It can take up to eight hours to get approval,” she said. “You have to send pictures, upload them, call, get approvals from a central health department and then go through the CDC (U.S. Centers for Disease Control and Prevention). And then once approved, then we can send the tests.”
The process is starting to improve, she said, as testing capacity expands beyond the CDC and state public health department laboratories. Monkeypox testing capability now includes five commercial labs — Aegis Science, Labcorp, Mayo Clinic Laboratories, Quest Diagnostics and Sonic Healthcare.
“These additional labs are going to be offering the test but there is a cost associated with it,” Abbo said.
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Those costs aren’t purely financial. The quickly spreading outbreak is raising concerns about whether the nation’s health system is equipped to combat yet another infectious disease outbreak in the midst of a coronavirus pandemic that’s stretched more than two years.
“This is also the burnout of the nurses, of the physicians, of the laboratory technicians, everyone who has been working nonstop for the last two years with a COVID pandemic. Now we have to focus still on COVID and on this new outbreak,” Abbo said. “We do need help with the treatment and access to rapid diagnosis.”
The Free Press surveyed eight major health systems in Michigan about their ability to test and treat monkeypox. Two, the Detroit Medical Center and Ascension Michigan, didn’t respond to questions.
Of the other six — Trinity Health Michigan, the University of Michigan Health, McLaren Health Care, Sparrow Health System, Henry Ford Health, and the BHSH System, which includes Beaumont Health and Spectrum Health sites — all said they have the ability to swab patients for monkeypox, but the samples must then be sent to the state Bureau of Laboratories for testing.
Results can take four to eight days to get back from the state lab, said John Foren, a spokesperson for Sparrow.
“We have performed two (negative) monkeypox tests on patients with rashes and viral symptoms,” Foren told the Free Press on Monday. “In both cases, we had to send the results out for analysis.”
Sparrow is in the process of developing its own monkeypox test, just as it did early in the coronavirus pandemic for the SARS-CoV-2 virus.
“We expect to do everything in-house in the near future,” Foren said. “That will speed up how soon we get results.”
The six-hospital system, based in Lansing, hopes to have monkeypox testing capabilities by late August, Foren said. With an in-house test, Sparrow would aim to get results within 24 hours.
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Beaumont Health also is working to develop its own monkeypox testing capabilities, said spokesperson Maryanne MacLeod. In the meantime, all Beaumont Health hospitals, emergency and urgent care centers collect samples from patients with swabs that are shipped to the state for testing.
“Testing teams review clinical symptoms, along with epidemiological information, such as recent travel to certain places, men who have sex with men, and known exposure, to determine eligibility for testing,” MacLeod said. “So far, we have received about 17-plus requests for monkeypox testing throughout Beaumont Health.
“Any patient with symptoms consistent with monkeypox and especially those with known or potential risk of exposure can be tested.”
At the University of Michigan Health, samples have been collected from the lesions of “a small number of patients” to test for monkeypox, said Dr. Laraine Washer, professor of infectious diseases at the University of Michigan Medical School and medical director of infection prevention and epidemiology at the University of Michigan Health. Those samples were then sent to the state Bureau of Laboratories for testing.
“Because of need for specific biosafety precautions, the test is not being performed in our clinical laboratory,” Washer said.
The decision about whether to test patients for monkeypox is “based upon clinical appearance of rash or genital lesions and whether the patient has a known or suspected exposure. Testing for other sexually transmitted diseases is typically done at the same time,” she said.
At Spectrum Health West Michigan and Spectrum Health Lakeland, 15 monkeypox samples had been collected as of Friday and sent to the state Bureau of Laboratories to be tested. Henry Ford Health said it had collected swabs from two suspected monkeypox patients and Trinity Health Michigan had collected samples from three patients that were all sent to the state lab for testing.
Chelsea Wuth, a spokesperson for the state health department, said monkeypox infections still are relatively rare, and that public health has scaled up appropriately to meet the challenge the virus has presented.
“There have been 1000-plus cases in the U.S. in the last two months,” she said. “The capacity to test, for example, is not the same as COVID. Those that need testing can be tested.”
She said the state health department can no longer track how many monkeypox tests have been completed.
“While the introduction of commercial laboratory testing into the process offers a significant improvement on testing capacity, since these tests are not being vetted through the public health department, we no longer have a way of knowing how many tests are run,” Wuth said. “The adequacy of the testing is now dependent on clinicians evaluating and testing cases appropriately.”
Once a test comes back positive, there is an antiviral medication called tecovirimat, also known as TPOXX, that can be prescribed.
It’s been authorized by the U.S. Food and Drug Administration under Investigational New Drug status and is held in the Strategic National Stockpile. Accessing TPOXX requires coordination with the CDC — and reams of paperwork, Foote said.
“It is 120 pages,” she said. “It’s quite complex, especially compared to some other IND protocols and very time-consuming to complete all the steps and paperwork and lab tests, etc.
“Because of these requirements, it’s really mostly our large academic systems with research experience that have the infrastructure to implement this IND protocol.”
It’s a process that can take up to three hours to complete, Foote said, and means patients being treated outside the large academic health systems may not be able to access TPOXX.
“In a busy community clinic, urgent care, emergency department, where most of these patients are being seen, this is nearly impossible to implement,” Foote said.
Of the patients with confirmed cases of monkeypox so far in Michigan, one has gotten the antiviral treatment, said Lynn Sutfin, a spokesperson for the state health department.
“TPOXX is being ordered after consultation between the patient’s provider and CDC,” she said.
Dr. Russ Lampen, an infectious disease specialist at Spectrum Health West Michigan, said because the majority of monkeypox cases are mild, “treatment with antiviral medications is not necessary.”
“Currently, a discussion with a physician at the CDC is required to have this medication released to patients,” Lampen said. “Most patients who would require TPOXX would likely be admitted to a hospital where ordering physicians would have the resources to handle the regulatory paperwork that IND medications require for release from the CDC.”
But Foote, in New York, said that even though some describe monkeypox infections as mild, they can still be debilitating.
“The reality on the ground is that a lot of people with this infection are really suffering, and some actually may be at risk for permanent damage and scarring,” she said. “We’ve seen many people with symptoms that are so severe that they are unable to go to the bathroom, urinate or eat without excruciating pain. And it’s really been striking to me how many of these patients have had difficulty getting the care they need to treat these symptoms, having to go between clinics, hospitals, urgent cares, sometimes never getting referred to us.”
About 70 patients in New York City had been treated with TPOXX as of Thursday, and reported significant improvement, she said.
“As our infection rates continue to rise, the system as it is now makes it nearly impossible to adequately scale up treatment,” Foote said.
“We are still really struggling to meet the demands. There are also very significant equity concerns over who can access treatment if it is mostly just available through academic centers. We worry that this could become a treatment only accessible by patients with privilege or that are very savvy navigating the complicated system.”
In addition to the TPOXX antiviral drug, there also is a smallpox and monkeypox vaccine called Jynneos that can be used to prevent disease or limit severity of symptoms.
Jynneos can be used after exposure to monkeypox to prevent illness or make it less severe in people ages 18 and older. It is given in two injections spaced four weeks apart.
However, the sooner the vaccine is given after exposure, the better. Ideally, a person who was exposed to monkeypox should get vaccinated within four days of exposure to prevent disease, or four to 14 days after exposure to limit the severity of disease, according to the CDC.
Supply of the Jynneos vaccine also is limited.
As of Friday, Michigan was on track to receive 1,786 doses in phase 2A of the federal distribution from the Strategic National Stockpile.
“These vaccines are limited and will be prioritized for post-exposure prophylaxis … for persons with a likely exposure,” Sutfin said. “This is a two-dose series, so the current supply will allow us to vaccinate less than 900 people.”
While the CDC does not advise widespread monkeypox vaccination, it suggests the vaccine may be recommended for people who:
- Have had confirmed close physical contact with someone diagnosed with monkeypox.
- Have a sexual partner who was diagnosed with the virus.
- May have been exposed.
- Are men who have sex with men who have recently had multiple sex partners in an area where monkeypox was confirmed or where the virus was spreading.
- Perform laboratory testing to diagnose monkeypox and may be at risk of exposure.
It can take up to 21 days for symptoms to develop after a person is infected, according to the CDC. But when symptoms first appear, they are typically flulike and include the swelling of lymph nodes, fever, headache, muscle aches, backache, chills and exhaustion along with a rash and lesions that may start in one place on the body and spread to other parts.
Lesions progress through stages and scab before falling off. The illness typically lasts two to four weeks.
If the U.S. can scale up testing, treatment and vaccine distribution, Abbo said there’s still a chance this monkeypox outbreak can be stopped.
“If we learned something from the COVID-19 pandemic, it’s that we need to pay attention to this so things don’t get worse,” Abbo, in Miami, said. “I hope it doesn’t become endemic. I hope that we come up with rapid diagnostic tests, point-of-care tests eventually. … I think stopping the chain of transmission is fundamental. We still have time to do it. We have time to do it globally and in the United States.”
Contact Kristen Shamus: firstname.lastname@example.org. Follow her on Twitter @kristenshamus.
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